Penn Healthcare Review Fall 2019 by Publications of the Wharton Undergraduate Healthcare Club

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Penn Healthcare Review PRODUCED BY

WHARTON UNDERGRADUATE HEALTHCARE CLUB

A Second Look at Health Inequities: Racism as a Public Health Issue â&#x20AC;&#x201D; page 20

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Penn Healthcare Review Editor-In-Chief Elaine Ma

Editorial

Aleksandra Golos Grace Mock Neelu Paleti Alan Chang Daniel Wittmer Claudia Hejazi-Garcia

Strategy and Design Judy Choi, Director Lachlan Cormie Farhaanah Mohideen Sarah Nam

Finance liaison Alan Chang

Where Business Meets Healthcare Dear Readers, Healthcare lies at the intersection of science, politics, sociology, and beyond. It is an area of dynamic advancement and yet persisting, deeprooted inequality. The future of health must be driven by innovative and, more importantly, compassionate minds. Now, more than ever, the pressing urgency for solutions must carefully consider both sustainability and equitability. I invite you to explore the multifaceted landscape of healthcare, as demonstrated by the diverse pieces featured in this issue. Our featured article by Christine Olaogun explores racism as an issue of public health. The physiological consequences of social inequality is particularly important to address, considering the tense political climate we find our nation in today. It can be challenging to forge interdisciplinary spaces where a wealth of topics and issues are discussed. With that being said, I am honored to present the Fall 2019 issue of Wharton Undergraduate Healthcare Club’s Penn Healthcare Review. Our editorial board, design team, and writers have brought this issue to life through their unwavering passion for healthcare. Each member of the team has brought a unique element of their background and together, synthesized this unique publication. It is our hope that Penn Healthcare Review will engender reflection and engagement with critical issues in healthcare. Sincerely, Elaine Ma, Editor-in-Chief

Interested in writing for Penn Healthcare Review? Email wuhc. pennhealthcarereview@gmail.com for more information. All cover, title, and infographics were designed by the Strategy and Design team members using Piktochart: “Easy to Use Infographic Maker.” Piktochart. https:// piktochart.com/ Subscription to PRO Plan from 11/17/2019 to 12/172019. Cover image courtesy of Online Marketing (@impulsq) on Unsplash.com. Edited on Piktochart by Judy Choi.

Please note: These articles were prepared by members of the Wharton Undergraduate Healthcare Club. The opinions do not represent the school’s or the club’s official position on the issues. Wharton Undergraduate Healthcare Club is an independent student-led organization of the Wharton School of the University of Pennsylvania. All content is the responsibility of the club.

Contents

The Market Failure of Surprise Medical Bills: Implications and Solutions BY MICHAEL MONTAGUE

Smokers Need Not Apply: Tobacco-Free Hiring Practices BY GRACE MOCK

Physicians as Notetakers? How Physician Roles Are Changing With Increasing Technology BY LANA SALLOUM

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Nurse Practitioner Postgraduate Training Programs: A New Model for Addressing the Primary Care Shortage? BY ALEKSANDRA GOLOS How the Proposed Single- Payer “Medicare for All” Could Impact the Middle-Class When Revenues Need to be Raised BY NICHOLAS POSIVAK Psychedelics and Possible Applications to the Opioid Crisis BY JERRY CAI

How the Reality of Incoming Patent Expirations is Driving Big Pharma’s Strategy BY DANIEL WITTMER

Eugenics: The Ethical Battle Between History & Biology BY CLAUDIA HEJAZI-GARCIA

Featured: A Second Look at Health Inequities: Racism as a Public Health Issue BY CHRISTINE OLAGUN-SAMUEL

CRISPR Screening: Finding the Root of the Problem BY ALAN CHANG

A Trifecta of Culpability: Factors Contributing to the Obesity Crisis & Possible Future Solutions BY SAKSHI SEHGAL

An Ethnographic Perspective on the Social Life of Maternal Mental Health in South Asia BY NEELU PALETI

PENN HEALTHCARE REVIEW

The Market Failure of Surprise Medical Bills: Implications and Solutions BY Michael Montague

or many Americans, receiving a bill from an insurer is a gamble. What lies in the envelope is a mystery for many patients, an unknown outcome that awaits as they ruminate over what they might be obligated to pay for a recent procedure or a trip to the Emergency Department (ED). A stinging reminder of the exorbitant price of health care, these bills often come without notice. Surprise bills can enrage patients over the lack of transparency, and even send patients into financial ruin. These bills stem from

market failure stems from a flaw in the arrangement of provider services in a hospital. Typically, a hospital contracts with a payer (an insurance company) to be a member of their care network. This arrangement allows for beneficiaries of that insurer’s plan coverage at that hospital. The issue lies with ancillary and specialist physician services. For an in-network physician, the prices for services are negotiated with the insurer to a lower rate. This rate is covered by the insurer on behalf

"Understanding surprise medical bills and the resulting market failure stems from a flaw in the arrangement of provider services in a hospital"

out-of-network physician services, transportation to a hospital, or emergency department fees. The potential for catastrophic damage caused by surprise medical bills has been routinely covered in the media, by policy advocates, and politicians alike.1 Despite this coverage, the market failure of surprise medical bills remains ambiguous, and, any potential policy solutions remain unclear. Understanding surprise medical bills and the resulting 4

of the beneficiary, the patient. If a physician is not out-ofnetwork, then the insurance company is not required to pay the bill for those services.2 In the ED, patients cannot ‘shop’ for their physician, and do not have the choice of what services will be provided. In light of the patient’s state, patients can end up with bills that reflect services they didn’t know they were provided while in the ED. A recent survey by The Commonwealth Fund found that

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nearly half of working adults indicated that they are not confident that they could pay a $1,000 surprise bill in 30 days.3 This clearly represents a market failure, and the supporting data suggests that it is more common than originally anticipated. Recent studies have shown the prevalence and impact of ED surprise bills, further underscoring the presence of a market failure. A study by Garmon and Chartock (2017) demonstrated that nearly 20% of ED inpatient visits resulted in a surprise medical bill. Certain states showed significant prevalence relative to the rest of the nation, as much as 50% incidence of surprise bills in states like Texas, Florida, and New York. Although some evidence shows a decline in the incidence of surprise bulling in recent years, it nevertheless represents a significant number of cases.4 Furthermore, outsourcing clinical services to private physician companies driven by vertical integration can provide an explanation for the explosion of costs. For example, physician management groups consisting of solely ED clinicians are contracted out to hospitals. A part of the problem lies in the organization of these contracts: these arrangements do not have to accept with the insurance that the hospital does.5 Large private equity firms have been rolling up these physician practices into physician staffing companies nationwide. Examples of these companies are Envision Healthcare and TeamHealth, owned by KKR and Blackstone respectively. As these companies grow, they are able to negotiate with payers to gain coverage for their services.6 There are inevitably gaps that are created by this two-pronged approach to payer coverage. Hospitals and these contracted groups can have incongruent payer networks, and this discrepancy gets passed to the patient. These private companies then reap the profits from higher out-of-network charges that would otherwise be covered if the physicians were provided by the hospital.

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An ongoing issue with the study of surprise billing is the unavailability of reliable data on outcomes and prevalence. In large part, contracting and billing information is proprietary as these private companies interact.7 On top of that, there is a dearth of data on outcomes of surprise bills, which often goes to arbitration.8 As legislation and pressures change, perhaps more of this data will become available for analysis and accountability purposes. Various policy efforts have been proposed to protect patients and physicians when it comes to surprise medical billing. There has recently been bipartisan support for such reform on Capitol Hill, but legislators are quickly realizing the complicated nature of solving the surprise bill problem. Current legislation proposes that insurers would pay the out-of-network bill as the average of what the other doctors nearby are paid. This, simply put, doesn’t cut it. Doctors would be paid much less for their services, and insurers would be on the hook for the hospital’s contracting practices.9 Any future should take aim at all stakeholders while preserving the payment for physicians and the financial security of the patient. Surprise medical bills remain a considerable problem in healthcare. Many patients do not know to ask, or even that it is possible that the doctor that they see in the ED does not accept their insurance. In light of the entrance of private equity to vertically integrating physician staffing and the increase in hospitals outsourcing clinical staff, surprise bills are becoming the focus of much needed debate to manage the complexities of provider-hospital arrangements. What seems to be an easy problem to fix is composed of parties with considerable conflicting incentives. Proposed solutions do not rest with Washington alone, rather with a change of incentives and market conditions to account for and ultimately eliminate this problem.

"20% of Emergency Department inpatient visits resulted in a surprise medical bill" *

*Christopher Garmon, Benjamin Chartock, “One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills,” Health Affairs 36, no. 1 (2017): 177-181.

Title and infographic designed by Sarah Nam | PHR Design Team 5

PENN HEALTHCARE REVIEW

Smokers Need Not Apply: Tobacco-Free Hiring Practices By Grace Mock

ike many Penn juniors, much of my semester has been consumed with the repetitive process of applying for summer internships. While I normally exist on autopilot when clicking through the repetitive questions about demographics, when applying for one particular position one of the fine print questions caught my attention. This particular company did not hire tobacco users and promised nicotine screening as a component of onboarding in the twenty-one states where such a policy is legal. To apply for the job, the application asserted, candidates needed to be nicotine-free for six months. While an unusual component for an internship application, the practice of screening out tobacco users in hiring, especially for hospitals and healthcare organizations, has become more common nationally in the past decade. Important questions linger implicitly within this practice. Does screening out smokers improve health and what social impact does this practice have?

Smokers and the Workplace

According to the Centers for Disease Control and Prevention, cigarette smoking is the top contributor to illness and death in the United States.1 Smoking is an individual action, but its harmful health effects extend to others, subjecting strangers to secondhand smoke in public spaces. A 2011 study found 19.6% of workers in the US smoked.1 Part of public disdain for smokers is that arguably most of the country has been educated about the dangers of smoking. Smokers choose to consume a product with detrimental health consequences. In many social and some financial ways, our society holds smokers accountable for their choice to smoke. However, not all populations are at equal risk for becoming smokers. Among adult daily smokers, 88% became smokers prior to adulthood. 2 This fact complicates 6

the claims of choice and personal responsibility, especially since there are strong ties to social factors that impact youth smoking uptake. According to the Centers for Disease Control and Prevention, smoking rates are highest among workers with no health insurance, living below the federal poverty line, and with less than a high school education.1 Approximately 69% of smokers express desire to quit, but only between 3 to 5% of unaided cessation attempts are successful.2 On average smokers individually cost employers over $3,000 annually in additional healthcare costs and lost productivity from smoke breaks.3 Under the Affordable Care Act, employers purchasing coverage on the smallgroup market are allowed to charge smoker employees a tobacco surcharge, or tobacco premium, up to 50% more than the community rated employee rate.4 If employees who are current smokers enroll in a program to quit smoking, they no longer pay the additional premium penalty.4 Notably, the American Lung Association opposes the use of tobacco surcharges as they “not been proven effective in encouraging smokers to quit.”4 Former practices, such as smoke-free work campuses and premium surcharges, shifted to the more extreme practice of not hiring between 2007 and 2013. Primarily implemented by hospitals and medical businesses, companies with tobacco free hiring practices assert the “policies advance[e] their institutional missions of promoting personal well-being and … reduce the growth in health care costs.”5

University of Pennsylvania Health System: A Case Study in Tpbacco-Free Hiring

The University of Pennsylvania Health System (UPHS) implemented tobacco-free hiring in 2013.6 UPHS requires all applicants, including physicians, to identify on

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their application if they smoke and will not hire anyone who is currently a tobacco-user. If an applicant lies and is later caught, they could face termination.6 However, if an employee is hired as a non-smoker and then begins to use tobacco products, they do not face termination but pay higher health insurance premiums.6 UPHS offers smoking cessation and nicotine replacement therapy for all employees, as support services to assist in quitting tobacco products.6 Not everyone believes the decision to eliminate smokers from hiring eligibility is fair. Dr. Frank Leone, Director of Penn’s Comprehensive Smoking Treatment Program, disagrees that the policy will improve health or lower health expenses.6 “It’s hard to imagine a person doing anything but really just hiding the fact that they’re a smoker. And once that happens, particularly in a healthcare institution, the chances they’ll go and seek care for the problem go down considerably in my mind,” he predicted in 2013 shortly before the policy became effective. Dr. Leone’s argument about the UPHS decision

is more salient when placed in the social context of Philadelphia. Philadelphia has the highest poverty rate of large cities in America, with 400,000 impoverished residents, contributing to the third greatest income gap in the country.7 It does not seem to be a coincidence that Philadelphia also has the highest adult smoking rate of large cities in America, and tobacco use is the leading cause of death in Philadelphia.7 In University City, where UPHS’s primary campuses are located, almost 40% of the population is living below the federal poverty level and approximately 20% of the population forwent healthcare due to cost in 2018.7 University City also has a 22% smoking rate, higher than the national average of 17%.7 For the University of Pennsylvania Health System to actively not hire smokers, it must be acknowledged that they are further limiting opportunities for individuals already facing systematic barriers and high unemployment. It seems, despite the intention of the practice of tobaccofree hiring, the outcome does not necessarily promote a healthier workplace.

"On average, smokers individually cost employers over $3,000 annually in additional healthcare costs and lost productivity from smoke breaks"* *“U Penn’s head of smoking treatment says no-hire rule for smokers is ‘regressive’.” WHYY, PBS. February 20, 2013.

Title and Infographic designed by Sarah Nam | PHR Design Team 7

PENN HEALTHCARE REVIEW

s we continue to progress into the 21st century, technology is largely seen as the reason why society develops so quickly. However, have we gotten to a point in healthcare where we simply do not need the vast amount of data that we are trying to collect? Epic Electronic Health Record (EHR), is the most popular national health record system which serves to consolidate previously separate data systems into one streamlined platform. Ideally, this would “help to improve clinical efficiency, boost patient safety, and streamline patient-provider communication”. In addition to increased efficacy and quality improvement, hospitals boast about all the money they will pocket over the years thanks to Epic, but many physicians are not as amused. In fact, many physicians believe that Epic is the start of the demise of physician-patient interaction. To investigate further, I set out to interview a practicing cardiologist who has his own practice and works at a Meridian Hospital in his area to ascertain where he feels the field of medicine is steering towards. The essential need for improvements in electronic records stems from systematic inefficiencies in healthcare, most notably the extremely long wait times to see physicians. However, Cardiologist Dr. Smith1 does not see Epic as a solution to helping more patients get access to a physician. Smith accredits these long wait times to the length of time it takes to groom one specialist and the subsequent undersupply of physician to meet the demand of the industry. In reality, Dr. Smith claims this new

documentation system may actually increase wait times or decrease the quality of care. Before Dr. Smith’s hospital switched to Epic, they were using Sorian. He admits that the systems that he used to input data were not streamlined, and that he spent half the time inputting data than he currently does with Epic. “Doctors have become notetakers and data gatherers rather than practicing physicians whose job is interacting with patients and improving their outcomes.” He says it now takes him 30-45 minutes to document his visits, which is threefold larger than the time he estimates he spends with a new hospital patient. For example, whenever he sees a new patient, he has to create an in-depth medications list for discharge. If a patient were on seizure medication for instance, he would have to explain why. Obviously, it is because the patient has epilepsy and experiences seizures, but he now has to write all of the scientific explanations in a time-consuming manner. This provides no benefit to the patient either because they are aware of their own condition and should be taking the medications. Additionally, there are also new electronic health apps like “MedClin” that have patients input their medical history, lab tests, radiology images, etc. While this may seem like an inspired idea, Dr. Smith says he would prefer that patients speak directly with their doctor about any issues or questions they may have rather than consulting with the apps on the market that have patients uploading their own charts and diagnoses. Doctors acknowledge that

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patient involvement in their own care is extremely important and improves patient outcomes, however, they affirm that medical records should not be left in the hands of the patients. There are too many variables at play and with the asymmetric nature of healthcare, it is too dangerous to leave critical aspects of a patient’s health in the hands of an app. It seems foolish that doctors with unique abilities and immense knowledge are being diminished to data enterers. After this conversation, I felt intrigued to ask him what this data is being used for. He replied that he “honestly has no idea what the hospitals are planning to use that data for in the future but that it has to do with the buzz words ‘big data.’” Have we become so caught up in analyzing every single step of healthcare delivery with data that we are slowing ourselves down? Dr. Smith says companies like Epic make it harder for him to see as many patients at his private practice and that many doctors he knows are simply scheduling fewer patients to

systems. Articles claim that Epic will save hospitals upwards of hundreds of millions over 20 years.2 This evidently seems like a huge portion of money; however, Smith says these estimates do not take into consideration growing inefficiency due to EHRs and the value of doctor’s time. Many doctors actually feel disrespected that their hospital implemented this new system without their input. He says, “physician time is limited and to spend half of their time entering data is ludicrous after the minimum 14 years they spend in school.” Furthermore, it seems that hundreds of millions are quite an overestimate considering it did not factor doctor’s seeing less patients due to their wasted time with Epic. While it seems great in theory to save money on the other systems that hospitals were previously using, if patient intake plummets by half, that a hundred million dollars will be a drop in a bucket compared to the money lost due to fewer patients being seen in hospitals using Epic.

account for the time lost to documentation. If this continues to be the case, fewer and fewer Americans will have access to doctors that they need but at least hospitals will have all of this “big data” that may or may not provide anything of value to these patients. Something doesn’t seem to be adding up here… Dr. Smith is definitely on the skeptical side saying that many surgeons he knows have actually switched hospitals so they did not have to waste large chunks of their time writing notes rather than doing procedures or interacting with patients. It is also important to examine the monetary considerations associated with Epic or other similar

On a more positive note, this does not have to be the demise of healthcare. Unfortunately, it seems like newer electronic records are not the panacea of healthcare efficiency. Dr. Smith is unsure how to fix this issue but he says that there needs to be a smarter, more user-friendly system that will not waste physician time but can still consolidate records into one accessible location.

Title and pull quote designed by Lachlan Cormie | PHR Design Team 9

PENN HEALTHCARE REVIEW

Nurse Practitioner Post-GraduatePro the Primary Car

By Aleksan

he primary care landscape in the United States has dramatically shifted in recent years. Factors such as the aging population, the increasing burden of chronic illnesses, the transition to value-based care, and the Affordable Care Act’s expansion of health insurance coverage have contributed to a shortage of primary care providers. Nurse practitioners, along with other midlevel providers, are commonly identified as a means of addressing this need in a way that does not involve the long and costly process of training more physicians. Becoming a nurse practitioner (NP) requires obtaining a graduate degree, such as a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP). After graduation and certification, NPs enjoy expanded practice authority. Depending on their state’s scope-of-practice laws, this may include the ability to diagnose patients, perform minor procedures, and prescribe medication.1 Expanding the scope of practice for nurse practitioners is a hotly-debated topic. A key argument against expansion is that nurse practitioners lack the training and experience necessary to operate as independent healthcare providers. Physicians spend years gaining medical knowledge and clinical experience beyond what they learn in medical school through postgraduate residencies and fellowships. In contrast to this, postgraduate training is often seen as unnecessary for nurse practitioners. Graduate degree programs were traditionally designed to build upon a foundation of extensive clinical experience, a decade on average, in general nursing. Based on rigorous MSN or DNP curricula, evidence-based competency metrics, and certification exams, NPs are often assumed to be fully prepared to provide high-quality care upon graduation.2 In a trend that challenged this assumption, the mid2000s saw new nurses quickly transitioning from training 10

in acute care institutions to practicing in primary care settings. Accelerated NP tracks also began to admit nurses who did not have any post-baccalaureate clinical experience.3 These practices allowed for the quick deployment of midlevel providers to underserved primary care settings, such as rural communities, low-income urban neighborhoods, or community health centers serving primarily elderly, disabled, and uninsured patients. However, inexperienced NPs frequently felt underprepared to care for this increasingly complex patient population and found the transition to practice difficult. To address this problem, Margaret Flinter, clinical director of Community Health Center, Inc. (CHCI; a Connecticut-based federallyqualified health center), developed the nation’s first nurse practitioner postgraduate training program in 2007. CHCI’s year-long program involves precepted and independent clinics, didactic learning sessions, formal mentorship, and rotations in specialties such as gerontology, pediatrics, and mental health.4 The “microsystem” model focuses on easing the transition to practice, featuring small program cohort sizes, clear leadership, patient-centered care, and modest expansion goals. CHCI’s model soon caught on among similar community health centers across the country. In 2018, a comprehensive review of NP postgraduate training programs found 53 active programs, with a marked increase in growth since 2014. Most programs were run by federally-qualified health centers, and the most common source of payment for services was Medicaid, indicating that the original vision of targeting underserved settings was preserved.5 Postgraduate training programs operating within a “microsystem” model show considerable promise in addressing the primary care shortage while easing the transition to practice. NPs express a salient need for

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ograms: A New Model for Addressing re Shortage?

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more clinical training, especially training specific to lowincome, chronically ill, and otherwise vulnerable patient populations. One study found that postgraduate training programs had a significant impact on nurse practitioner job satisfaction across domains such as collegiality, autonomy, interaction, and growth.6 While most research has centered around the perspective of NPs rather than patients, increased confidence, strengthened role identities, and enhanced clinical skills could conceivably translate to better patient care. Still, a number of criticisms are voiced against postgraduate training programs, in light of the debate over scope-of-practice laws. Entities such as the Nurse Practitioner Roundtable argue that the MSN or DNP degrees required for nurse practitioner certification provides adequate preparation, and that postgraduate training programs impose needless delays and financial burdens.7 Moreover, constraints such as small cohort sizes, few preceptors and faculty, and limited government funding limit the provision and adoption of these programs. Finally, the hyper-specialized “microsystem” model could arguably make it difficult to design standardized program features and performance metrics, leading to extreme variation in program quality and outcomes. Despite these challenges, NP postgraduate training programs are positioned to take advantage of key growth opportunities. As early as 2010, an Institute of Medicine report recommended all new or transitioning advance practice nurses to enroll in postgraduate training programs following the completion of an MSN or DNP. A 2015 update to the report further endorsed the expansion of nurse practitioner education, including greater funding and development of postgraduate training programs.8 Even the aforementioned skeptical Nurse Practitioner Roundtable report identified the value of

Title designed by Sarah Nam | PHR Design Team postgraduate training programs for NPs working in “communities where significant financial, social, and emotional comorbidities make traditional management of health more challenging.”9 Adoption may therefore be encouraged if the benefits of the postgraduate training program’s “microsystem” model are differentiated from the benefits of MSN and DNP programs. Graduate degree programs are run at academic institutions (or even online), which involves some degree of separation from underserved communities that have the greatest need for nurse practitioners. The advantage of postgraduate programs that focus on the transition to practice therefore lies in developing the skills and knowledge that NPs need in order to excel in their individual environments. Julie Sochalski, former director of the US Department of Health & Human Services Division of Nursing and current Associate Dean for Academic Programs at Penn Nursing, emphasizes this point: “despite the continued expansion of DNP programs, the need for expanding advanced clinical training for NPs continues.”10 Time will tell whether nurse practitioner postgraduate training programs truly generate superior outcomes for trainees, patients, and the primary care system as a whole. However, legislators and program directors can lay the foundation for their long-term expansion and improvement. Evaluating outcomes using standardized criteria that align with the “microsystem” model will differentiate their benefits from those of the MSN and DNP. Furthermore, this will demonstrate their value over direct entry into practice and help mitigate current barriers to adoption. With this in mind, nurse practitioner postgraduate training programs may soon become a fixture of the primary care environment. 11

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How the Proposed SingleP a y e r “ M e d i c a r e f o r A l l” C o u l d Impact the Middle-Class When Revenues Need to be Raised

ith multiple candidates in the 2020 Presidential Election endorsing a move to a singlepayer health care plan, coined appropriately “Medicare For All,” there is much speculation across party lines as to how the plan will be financed and in turn, how it would affect middle-class Americans. Senator Elizabeth Warren from Massachusetts has promised that costs for the middle-class “would not go up one penny” on her health care plan over the next ten years, but is this possible? I hope to break down the Senator’s plan and review the proposed financing details to analyze if it is indeed possible to raise the revenues necessary to fund Medicare For All while not imposing a tax hike on the middle-class. “Today, in 2019, in the United States of America, the wealthiest nation in the history of the world, inadequate health coverage is crushing the finances and ruining the lives of tens of millions of Amer-ican families.”1 Warren’s pitch for universal healthcare is a strong and compelling one, citing healthcare as a basic human right and demanding that “nobody go broke because of a medical bill.” At its simplest, Medicare For All promises to provide better coverage to more people for less money. She plans to achieve this by slashing insurance company profits, provider bureaucracy, and excessive drug prices

B y N i c h o l a s P o s i v a k

while also eliminating all premiums, co-pays, deductibles and out-of-network bills. Addi-tionally, her plan includes new taxes on the financial industry, big corporations and the top 1% of Americans while cracking down on tax evasion and fraud to ensure that everyone pays their fair share. With all of this in action, Warren and her campaign believe that $34 trillion will be raised and fully fund her 10 year plan. But herein lies the issue. Economists agree that these ambitious goals for Med-icare For All carry a valuation trillions of dollars higher than Warren’s.2 This valuation gap is incred-ibly important, as it basically determines whether or not the plan can be financed without raising costs for the middle-class, as promised. Even former Vice President Joe Biden’s campaign sounded off on the Senator’s financing report in a statement saying, “The mathematical gymnastics in this plan are all geared towards hiding a simple truth from voters: It’s impossible to pay for Medicare for All without middle class tax increases.”3 So how is Senator Warren’s valuation so much less than that of top economists? “To accomplish this sleight of hand, her proposal dramatically understates its cost, overstates its savings, inflates the reve-nue, and pretends that an employer payroll tax increase is something else.4

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” This is dangerous, as the muddy finances lead her voters down a path of blind support, not aware of what they could poten-tially be in for if or when additional revenues must be raised. Even with increased taxes on the wealthiest Americans, the financial industry, and big corporations, revenues required for the plan to be rolledout probably won’t be reached, leaving middle-class Americans to foot the bill. Some believe Warren is selling an illusion as political courage. Some believe she has figured out a potential way to drive down costs.5 Even if her valuation is correct,

keeping the cost to that level would require, “heroic” assumptions about how much savings could be squeezed from every corner of the health-care system.6 Regardless of opinion, it’s safe to say that the topic of healthcare and healthcare spending will be the top issue in the 2020 Presidential Election and middle-class Ameri-cans should be wary of what that could potentially mean for them.

“To accomplish this sleight of hand, her proposal dramatically understates its cost, overstates its savings, inflates the revenue, and pretends that an employer payroll tax increase is something else.”*

*Luhby, Krieg, Lee, &amp; Santiago. “Warren Releases Plan to Fund Medicare For All, Pledges No Middle Class Tax Hike,” 2019.

Title and pull quote designed by Judy Choi | PHR Design Team 13

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Psychedelics and Possible Applications to the Opioid Crisis By Jerry Cai

alking along the streets, one can see used needles and empty medicine vials scattered on the curbsides. Funerals are held for those who can afford them, while those less fortunate are left on their own. From the urban San Diego to rural Appalachian towns of Wise, these are common sights as the decade-long opioid epidemic rolls on. The crisis is claiming 192 lives each day and has resulted in an estimated 70,000 deaths in 2017 according to the United States Department of Health and Human Services. This figure is still climbing as of now, even as the United States has called a State of Emergency.1 A larger proportion of consumption comes from black market and street drugs such as fentanyl, cocaine and heroin, which have become easier to obtain and cheaper to purchase than their prescription counterparts. The substances of interest remain prescribed opioids, under brand names like Percocet, Oxytocin and Vicodin. The United States health care system is known for its high prescription rate, which reflects a troubling trend in primary care, as drug manufactures advertise their products directly to the patients and doctors. These factors have incentivized drug prescription for pain management in a wider range of ailments. According to a comprehensive study conducted by Rudd, Aleshire and Zibbell, pharmaceutical companies significantly directed advertising efforts towards areas, such as Appalachia, whose residents are more prone to develop dependency and ultimately overdose. Haglund has also found that about 1 in 5 family physicians are have received pharmaceutical promotions in the form of meals or indirect payments, totaling tens of millions of dollars in expenditures.2 14

The Center of Disease Control has focused on improving data collection, resource availability and the establishment of new drug prescription guidelines. Current methods of treatment involve behavioral therapy coupled with anti-opioid drugs such as methadone, buprenorphine or naloxone. The National Institute on Drug Abuse has reported that less than half of all treatment centers provide these drugs free of cost, and that admission into opioid rehabilitation programs have actually decreased, despite a shortage of space in treatment centers. These medications are opioid agonists, which bind to the opioid receptors on neurons without producing a sense of euphoria. The mechanism allows withdrawal symptoms to be largely repressed, but these interventions create inherent risks on their own. In addition, this approach must be coupled with consistent adherence to treatment plans, with most centers employing an abstinence-only philosophy.3 Recently this September, the Johns Hopkins Center of Psychedelic Research was launched off of a 17 million dollar grant to explore possible therapeutic applications of psychedelic drugs. “The center’s establishment reflects a new era of research in therapeutics and the mind through studying this unique and remarkable class of pharmacological compounds,” says Roland Griffiths, the center’s director and professor of behavioral biology in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.4 The institute has received legal approval from government regulators, the first of its kind at a large, private medical research center. Psychedelics have become the umbrella term for substances such as Lysergic Acid, Psilocybin, and

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Ibogaine. These psychedelics have been deemed Schedule 1 substances since the late 1970s due to its close association with the counterculture movement. In his book How to Change Your Mind, Michael Pollan traces the history of such substances from its early stages of development in a Swiss laboratory, hailed as a medical miracle for its potential value in a panacea of mental conditions, such as epilepsy, bipolarism and severe clinical depression.5 The benefits in behavioral influence have been cited by translational studies assessing psychedelics’ biomedical basis of efficacy. Another study conducted by Winkelman examined how the serotonin neurotransmitter system would be affected by the dynamics of certain psychedelic drugs, such as a reported “afterglow” effect and sensations of diminished anxiety. Psychedelics have demonstrated a remarkable ability to render users in a state of interconnectedness with objects and derive meaning out of experiences during their treatment session.6 They have also displayed little to no toxicological effects or addictive properties when administered in prescribed amounts,

an important aspect when considering its potential in addiction therapy use. In the context of the nation’s worst opioid epidemic, health officials are looking beyond traditional opioid receptor antagonist compounds for a diverse array of drugs that can be adapted in multiple treatment approaches. Psychedelics are slowly gaining traction as an alternative method of treatment for addiction, following a dormant period of exclusion from mainstream research. Several psychedelics are naturally occurring compounds, meaning significantly to output compared to other artificially synthesized drugs in development. However, psychedelics are being approached cautiously even in light of promising leads, a complete assessment on its psychological and physiological effects is necessary to understand its therapeutic function. As the ongoing epidemic continues its sweep across communities, the nation searches for immediate solutions to care for victims and long-term solutions that can entirely reshape how pain management is approached.

Psychedelics at a glance: Psychedelics have become the umbrella term for substances such as Lysergic Acid, Psilocybin, and Ibogaine. These psychedelics have been deemed Schedule 1 substances since the late 1970s due to its close association with the counterculture movement. The serotonin neurotransmitter system would be affected by the dynamics of certain psychedelic drugs, such as a reported “afterglow” effect and sensations of diminished anxiety.* *Winkelman, Michael. 2015. &quot;Psychedelics As Medicines For Substance Abuse Rehabilitation: Evaluating Treatments With LSD, Peyote, Ibogaine And Ayahuasca&quot;. Current Drug Abuse Reviews 7 (2): 101-116.

Title and Infographic designed by Judy Choi | PHR Design Team 15

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How the Reality of Incoming Patent Expirations is Driving Big Pharma’s Strategy By Daniel Wittmer

he creation of patent law has driven profit margins across multiple companies and industries. A patent is essentially a document that allows the creator to protect intellectual and technical information surrounding a process or solution.1 Patent law, while the patent is in effect, works to impede spinoff products and services from flooding the market. Therefore, patent law protects intellectual property that’s the unique invention and innovation of its inventors for a set time.2 Because of this, patent law takes a lot of competition out of the picture, barring substitute products, which allows higher price levels by firms and, ultimately, larger margins. However, the term patent cliff describes the sharp decline in revenues experienced after one of a company’s most profitable products goes off patent.3 In addition, competition further drives a smaller and smaller wedge between the cost to the corporation and the price to be set for the consumer. This makes margins very thin, and can impact a company’s growth long-term.3 However, how does patent law affect the pharmaceutical industry, specifically? What does a pharmaceutical company do in response to an expired patent for their most profitable drug? These two critical questions reflect the strategy that pharmaceutical companies must employ to stay afloat with competitive market share once intellectual property is offpatent. To start, after a pharmaceutical company has a novel chemical treatment for a disease, the firm files for a patent with the United States Patent and Trademark Office (USPTO).4 This happens in the preclinical stage for a pharmaceutical company, before entering Phase I trials, and that’s when the 20 year patent timeline begins.4 This further poses a problem for these companies, as the drug has to advance through Phase III and, ultimately, Food and Drug Administration (FDA) approval to sell to the public market in Phase IV. To put that in perspective, if a patent application was filed in 2019, the patent wasn’t approved until 2023, and the FDA approval came a decade later for the drug in

2033, then there are only six years left on the patent. However, a company can apply for an extension that does not increase the patent term past 14 years, and the extension can only be half of the drug review period by the FDA.4 As you can see, the regulations surrounding products in the pharmaceutical industry can limit a lot of the intellectual property protection under patent law, and this further poses issues to pharmaceutical companies. In fact, Patent law on top-selling drugs is especially relevant as we start to move into 2020 and the very near foreseeable future. This is because the Mood Report, a global leader in financial analysis, found that powerhouse pharmaceutical companies such as AbbVie, Pfizer, and Bristol-Myers Squibb all have high revenue-driving products that are expected to expire between 2022 and 2028.5 For example, Humira is AbbVie’s number one selling product, and it is the world’s best-selling drug. In 2018 alone, Humira, also known as adalimumab, netted 20 billion in total sales.6 With the therapeutic accounting for 70% of total revenue for AbbVie, a company ranked eighth by market share, according to GlobalData, the loss of patent protection could send shares plummeting in the next couple of years.7 This one example highlights the reality of competitors quickly taking over products by flooding the markets with generics once patent protection is null and void. What do pharmaceutical companies do to avoid catastrophic losses in market share over the long-term once generics over-take their premier drugs? Mergers and acquisitions (M&A) have become the backbone of the industry’s front office strategy. For example, GSK acquired Tesaro for $5.1 Billion, Roche plans to acquire Spark Therapeutics for $4.3 Billion, and Takeda dug deep into its pockets to spend 62 billion when buying out Shire.8 All of these companies have

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drugs that are teetering on the patent cliff. Whether it be GSK’s blockbuster drug Advair or Roche’s highvalue therapeutic Xolair, the fear of losing competitive advantage is very real across the industry.9 In addition, even AbbVie acquired Allergan for $63 billion.10 In this situation, AbbVie is diversifying away from immunology and hematology and going into more aesthetics and neurology based treatments offered by Allergan. Instead of diversifying away from core competencies into other profitable ventures, we also see companies trying to build upon their already valuable research areas.10 For example, as previously mentioned, Takeda bought Shire for $62 Billion.10 Takeda focuses mainly on gastroenterology and inflammation, and Shire also has multiple products in these research areas.

Lastly, synergies, which are the results of aligned capabilities, value, and performance between companies involved in an M&A deal, are a result and driver of these transactions. The two main kinds of synergies are revenue and cost synergies. Revenue synergies can be achieved in this space, mainly through a reduction in competition.13 If a large pharmaceutical company can gain market share dramatically through a new acquisition, it can outcompete incumbents in the market in some instances. In addition, cost synergies look to create an impactful effect from an operations perspective. Cost synergies are typically more easily viewed over revenue synergies as streamlined processes, and new product channels can physically reduce costs to a company.13 For example, large pharmaceutical companies have more extensive distribution networks and more streamlined manufacturing processes than the

"Why can innovation be so challenging in today’s scientific ecosystem?" These deals highlight a few of the multi-billion dollar deals companies are making roughly three to five years before patents fully expire.11 Besides completely replacing or adding on to an original pipeline, there are other reasons why pharmaceutical companies employ an M&A strategy. According to PhRMA’s Biopharmaceutical Research & Development report, The average cost to research and develop a drug is around $2.6 billion. In addition, the timeline is, on average, ten years from bench to bedside.12 Also, besides substantial costs and time, the success rate to get a discovery from preclinical studies into clinical and eventual FDA approval is less than 12%.12 As science continues to move forward, the complexities behind discoveries are dramatically increasing. As therapeutics have been discovered and marketed for decades now, creating novel therapeutics is increasingly challenging as multiple needs have already been fulfilled. With this reality, pharmaceutical companies find it easier and less risky on average to acquire an outside innovation that is already in late-stage clinical trials or has been recently FDA approved.

majority of biotechnology companies they are acquiring. This can dramatically reduce the costs of creating the therapeutic and thus create added value to the firm. In conclusion, patent cliffs are now on the rise in the pharmaceutical industry across multiple large players in the sector itself. Because of this, M&A strategy has ramped up significantly. In fact, in 2018, there were 1281 biotechnology M&A deals verses 760 only five years prior in 2013.14 The next five years are a crucial time to watch for more M&A deal flow as more and more companies experience patent cliffs on their top-selling products. With these patents, expirations will also come lowered prices to consumers via competition from generics. It’s an exciting time to watch industry trends at this juncture, and only time will tell if the M&A deal trend will continue to ramp up.

Title and pull quote designed by Lachlan Cormie | PHR Design Team 17

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Eugenics: The Ethical Battle Between History & Biology By Claudia Hejazi-Garcia

“Three generations of imbeciles are enough.” These are the infamous words of Justice Oliver Holmes that will forever haunt the world of modern genetics. In 1927, the Supreme Court ruled that the state of Virginia was authorized to sterilize certain mental patients without consent1. Those deemed unfit to reproduce were forbidden from conceiving and forced to segregate themselves with fellow social undesirables in the United States. Eugenics is widely known as the science of controlled breeding to improve characteristics of the human race. has been a controversial topic of debate in groups from ancient philosophers to modern biologists. References to whether humans have the ability to select favored traits that offer less disabilities or appear physically superior are written in ancient literature like The Republic and envisioned in current scientific experiments such as CRISPR. Especially in the 21st century, science is advancing towards the ability to create “superior” humans with almost no laws regulating eugenics internationally. Throughout history, eugenics has always been a popular idea. Philosopher Plato vouches toward creating a fictional utopian society that may be an example to other populations and creating a race superior through selective mating. However, in the field of biology, researcher Charles Darwin argues that embracing diversity through mutations can scientifically offer animals advantages for their own survival and produce more diverse offspring. Ultimately, both thinkers believe that their ideas or methods may be the best way for humanity to survive for generations to come. Although eugenics has negative connotations today, both authors offer compelling attempts to understand how their idea of natural selection may benefit their societies socially and biologically. Athenian philosopher Plato argues in one of his bestknown literary works, The Republic, that creating a superior society can be accomplished by allowing higher-class citizens to reproduce with each other in order to create an “optimal world”. He emphasizes that creating a productive society can only be achieved under the rule of the best mem18

bers of society. Since he fears that inferior men and women will ruin his utopian world, Plato urges society to banish and suppress them from interacting with the elite members of the empire. He ensures that he wants “[the] herd to be of the highest possible quality” to protect the rest of his race and guarantee their longevity2. With Plato’s ideal empire, he suggests that his higher-class society needs to survive and take advantage of their environment by reproducing with each other. On the other hand, Darwin argues that diversity is necessary for natural selection and producing variation is essential for human survival in the real world. He writes, “the preservation of favorable individual differences, I have called Natural Selection”3. His famous statement stresses the point that no two individuals are alike, and humans can change in different environments and times in their life. He believes that nature is the true judge of whether a species has the ability to live or die. Darwin claims that if traits are man-made, they cannot be as favored in the future with the changing environment, which directly contrasts Plato’s idealist theory in The Republic. To Darwin, nature had the most impactful role on the present and future, forwarding evolution without human interference. Presently, modern eugenics is becoming increasingly significant as the majority of the United States seeks to justify the efforts of the U.S. elites by controlling reproduction. Much like Plato’s concept in The Republic, Francis Galton, a researcher in 1883, began to experiment with perfecting the human race as getting rid of its undesirables4. Due to the mentality of reproducing characteristics that seem to determine success from socially relevant standards, it can almost seem impossible to change and move up in society for marginalized populations. The eugenic belief that “social inequalities stem from biological differences” survive into modern day. Pew researchers even found that 43% of people who were raised in a minority family at the bottom of the income ladder stay there mostly due to implicit racist bias and lack of economic mobility5. Gradual evolution seems impossible and discouraged by the upper class; therefore,

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socioeconomic groups roughly stay the same over lifetimes. Using Plato’s ideals for a utopian society, this gradual evolution seems impossible due to the immediate effect that manmade selection should have on the community. Through Darwin’s real-life ideas, however, natural selection becomes favorable and makes it possible for evolution and change through classes over a continuous, prolonged growth. Additionally, the Virginian case mentioned in the introduction isn’t the only instance that sterilization had been forced onto those deemed socially inadequate by fellow humans. In 1930, Menendez Ramos, governor of Puerto Rico, initiated sterilization for Puerto Rican women to prevent the Aryan genes from being contaminated with Latino blood. Moreover, in 1976, 25-50 percent of Native American women were sterilized by the U.S. government to battle “Indian poverty” and improve their financial situations6. Unfortunate-

By comparing both of the streams to each other, one may see multiple perspectives of eugenics and how natural selection may be used to help species. Plato creates an ideal society where, essentially, citizens will become happier. Much like Darwin, Plato desires a society that seeks to elevate human society both economically and morally. However, Plato’s ideals turn destructive and unethical when applied to eugenics-inspired creations like the Aryan race in the Holocaust. Darwin trusts that selection made by nature will evolve dominant traits over time to help society while Plato’s ideals believes it may be better for society if selection becomes forced by humans. Based on their texts, Darwin and Plato seem likely to differ greatly with their approaches to the Virginian case. Yet, I believe that eugenics is a closed case. No one should have the ability to scientifically alter the traits of another human. I’m sure that both Plato and Darwin would

The Ethical Dilemma Plato's Ideals

Darwinian Thought

In his society of the elites, Plato suggests that a higherclass society needs to survive and take advantage of their environment by reproducing with each other. Plato’s ideals rationalize eugenics, with the belief that it may be better for society if selection becomes forced by humans.

Darwin argues that nature is the ultimate judge of whether a species has the ability to live or die. Eugenics opposes the Darwinian concept that natural selection favorably makes possible for evolution and change through classes over continuous, prolonged growth in a species.

Title and infographic designed by Farhaanah Mohideen | PHR Design Team ly, these instances still lead to explicit bias towards human populations that are wrongly assumed genetically different. Darwin rejects this idea of genetic difference by declaring no fundamental difference between varieties and species. Especially through the lens of modern eugenics, these genetic connotations become dangerous as the idea of natural selection begins targeting minority groups seen as socially unfit like Plato’s ideal society in The Republic. Although Plato never intends to have these ideals in the real world, they manifest to suppress smaller, vulnerable groups. Therefore, it becomes imperative to understand that racial bias is continuous today and being aware of this injustice can help lessen its future replication.

agree. Overall, personalized medicine is a revolutionary advancement in medicine that will improve healthcare immensely in the years to come. Although funding for this initiative was relatively liberal during the past few years, recent changes in the U.S. government may reverse such an attitude toward personalized medicine, as the Trump administration is much more conservative on social and fiscal issues than previous governments. It remains to be seen how this initiative develops throughout the world in the years to come.

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n December 30, 2017 Erica Garner, an activist and the daughter of Eric Garner, who died during an arrest by police officers in 2014, passed away at the young age of 271. Her death occurred while in a medically induced coma, following a heart attack that stemmed from asthma. One may attribute her death to complications related to her history of hypertension and asthma, but perhaps an often overlooked underlying health concern, prevalent in black communities, contributed to her illnesses and early demise: psychosocial stress. Inequities in healthcare provision and coverage have impacted minority black communities for centuries, and is frequently cited as the root cause of the high premature mortality rates amongst black populations in the United States. Studies in medical bias have examined the role that race has played in shaping medical practices, many times to the detriment of patients. However, discussions around healthcare disparities often focus more on the deficiencies in the existing insurance systems, housing inequities, and other structural imbalances, and less on the physiological and psychological consequences of racism, and how these may serve as an underlying mechanism of sickness2. Studies have shown that prolonged exposure to discriminatory experiences can result in a type of psychosocial stress which in turn can severely impact physiological and psychological health outcomes3. Most evidently, discriminatory experiences lead to chronic psychosocial stress, which can have a significant impact on mental health. Dr. David Williams, a professor at Harvardâ&#x20AC;&#x2122;s Chan School of Public Health, in conjunction with Atheendar S. Venkataramani MD, PhD at Pennâ&#x20AC;&#x2122;s Perelman School of Medicine, found that repeated exposure to episodes of institutional discrimination, specifically in the form of police brutality, has been severely damaging to the mental health 2

of many black Americans4. Their study indicated that witnessing the effects of police brutality contributed to more than 55 million more poor mental health days every year amongst black Americans in the United States compared to their white counterparts5. This statistic is comparable to the effect of diabetes on mental health, which is responsible for 75 million poor mental health days among black Americans6. Poor mental health is, however, not the only observable consequencse of discrimination induced stress. Prolonged exposure to discrimination, either explicitly or implicitly, may also elicit other significant physiological responses. Sherman James, a distinguished epidemiologist at Duke, coined the term John Henryism to describe the stressed physiological reaction evoked in the body in the quest to cope with distress from experienced discrimination7. Such reactions, can make the body overwork itself and may, in turn, result in complications in cardiovascular and renal health. Studies have documented the association between experiences of continuous discrimination and the prevalence of certain diseases linked to psychosocial stress. A University of Florida study found that age-adjusted mortality rates for black Americans were more than 30% higher than their white counterparts and were largely linked to higher rates of cardiovascular disease (CVD), end-stage renal disease, and diabetes, diseases all impacted by stress exposure8. Other studies have also shown that African Americans overall experience higher levels of reported racial discrimination associated with poorer self-rated physical and oral health9. Black women who attribute their everyday discriminatory experiences to racial rather than non-racial causes had higher levels of cardiovascular reactivity than their white counterparts 10 . Overall, black respondents had higher odds of a myriad of health problems and chronic issues compared to white re-

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spondents. Investigators were able to conclude that any form of continuous everyday discrimination was associated with poorer health, increased risk of physical health problems and a significantly higher likelihood of chronic health issues interfering with one’s daily life11. The common theme of many statistically significant morbidity inequalities amongst African Americans is that chronic diseases such as hypertension and CVD, that were found to be 34% more common in African Americans, were traditionally associated with high levels of stress12. Clearly, racism, though a sociocultural phenomenon, has significant biological consequences for the impacted populations. Whether the consequences are a result of systematic institutional structures that limit access to particular resources such as fresh produce, unbiased physicians and timely diagnostic tools, or the result of discriminatory experiences that cause stress-related diseases, the relationship between health outcomes and race is undeniable. The resulting health disparities have far reaching consequences, even impacting the health of future generations. A Johns Hopkins study showed a striking correlation between racism-induced psychosocial stress and preterm births, signifying that continuously experienced discrimination was associated with a

higher likelihood of pre-term births13. The factors contributing to health disparities in black populations are multifaceted and the initiatives to redress the disparities must equally be multifaceted. Creative programs need to be designed to target diseases with high prevalence in black communities. Community based initiatives, such as the barbershop intervention championed by Dr. Joseph Ravenell, and similar programs targeting black men take two factors into account: the prevalence of issues of hypertension and CVD in the black community, and the need for safe spaces unbridled by implicit bias and other race-based practices14. These programs are providing timely and supportive cardiovascular health resources for black men in barbershops, recognizing that for many black men treat their barbers serves as long-term confidants15. Similar programs across the country are adopting innovative methods to transform the health status of black communities by pinpointing the health needs of specific communities and providing safe spaces to access necessary healthcare. Indeed, community based efforts like these are critical pieces of the puzzle in closing the equity gap in healthcare for black populations and should continue to receive government funding and support. receive government funding and support.

Health Issues as an Indicator of Psychosocial Stress Health Issues as an Indicator of Psychosocial Stress Black Americans are largely linked to higher rates of cardiovascular disease (CVD), end-stage renal Black Americans are largely disease, and linked to higher rates diabetes, diseases all of cardiovascular disease impacted by stress exposure (CVD), end-stage renal disease, and diabetes, diseases all impacted by stress exposure

34% 34% Chronic diseases such as hypertension and CVD, that were found to be 34% more common in African Chronic Americans, diseases such as hypertension were traditionally associated andwith CVD,high thatlevels were of found to be stress* 34% more common in African Americans, were traditionally associated with high levels of stress*

African Americans experience higher levels of reported racial discrimination African associated with poorer selfAmericans experience rated higher levels reported physical and of oral health racial discrimination associated with poorer selfrated physical and oral health

Title and infographic designed by Farhaanah Mohideen | PHR Design Team

30% higher age-adjusted mortality rates than their white 30% higher counterparts age-adjusted mortality rates than their white counterparts

55M 55M Witnessing the effects of police brutality contributed to more than 55 million more poor mental health days every Witnessing theblack effects of police year amongst Americans brutality contributed to more in the United States compared thanto55their million more white poor mental health days every counterparts** year amongst black Americans in the United States compared to their white counterparts** *Mouzon, D. M., Taylor, R. J., Woodward, A. T., &amp; Chatters, L. M. (2016). Everyday Racial Discrimination, Everyday Non-Racial Discrimination, and Physical Health Among African-Americans. Journal of Ethnic &amp; Cultural Diversity in Social Work,26(1-2), 68-80. **Bor, J., Venkataramani, A. S., Williams, D. R., &amp; Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of black Americans: A population-based, quasi-experimental study. The Lancet. *Mouzon, D. M., Taylor, R. J., Woodward, A. T., &amp; Chatters, L. M. (2016). Everyday Racial Discrimination, Everyday Non-Racial Discrimination, and Physical Health Among African-Americans. Journal of Ethnic &amp; 21 Cultural Diversity in Social Work,26(1-2), 68-80. **Bor, J., Venkataramani, A. S., Williams, D. R., &amp; Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of black Americans: A population-based, quasi-experimental study. The Lancet.

PENN HEALTHCARE REVIEW

CRISPR Screening: Finding the Root of the Problem

t is impossible to discuss the future of precision medicine without mentioning the CRISPR-Cas9 system. Ever since CRISPRâ&#x20AC;&#x2122;s discovery in bacteria a few years ago, researchers have leveraged its DNA/RNA cleavage capabilities to develop an unprecedentedly precise and cost-effective gene-editing tool. Surpassing past methods of targeted engineering, many look to CRISPR for revolutionizing the world of personalized medicine.1 With that said, the common connotation of CRISPR is very limited: CRISPR has far more versatility than correcting mutations and delivering healthy versions of genes. Most of CRISPRâ&#x20AC;&#x2122;s vast potential comes from its ability to serve as a genomic screening tool. By mutating thousands of places in the genome, researchers can correlate these genetic changes to physiological changes to conclude gene-phenotype associations.2 Ever since the development of CRISPR screening, researchers have more clearly understood the function of countless genes and pathways, ranging from drivers of tumorigenesis to changes affecting immunological function.3 Furthermore, less than a month ago, researchers led by Dr. Martin Kampmann at UC San Francisco were the first to apply CRISPR screening to study stem cells.4 Kampmann 22

and his team were able to draw various important conclusions, identifying genes that increased neuronal life span, pinpointing genes that drove neurological diseases, and discovering unique behaviors of certain genes in neurons and stem cells. Understanding the expression and functions of such key genes, especially at an early stage, could greatly facilitate future genetic diagnoses. Thus, as demonstrated by Kampmann and his team, when assessing the future potential of CRISPR, it is important that we recognize its application to improved diagnoses in addition to gene therapy. With more electronic health record (EHR) development, increased sequencing precision, and CRISPR optimization, CRISPR screening will likely lead the future of personalized diagnostics. As we continue elucidating the underlying genetic drivers of many unresolved diseases with CRISPR screening, we will hopefully be able to effectively diagnose diseases early on via whole genome sequencing (WGS). Similar to how we can analyze mutations in dystrophin to diagnose Duchenne muscular dystrophy,5 one day we can hopefully develop an elaborate gene-phenotype association database that can facilitate personalized gene-based diagnoses. Furthermore, we can also apply the CRISPR-Cas9 system

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to carry out treatment after diagnoses. As we continue engineering. Making this form of precision medicine to improve CRISPR, such as via shortening sgRNAs, more accessible to people of various socioeconomic and replacing the Cas9 endonuclease, and decreasing off- cultural backgrounds will be another obstacle that, in target effects, it will be capable of clinically reliable human addition to all the scientific challenges, makes the dream genetic mutations.6 Taken together, CRISPR has such of CRISPR-based personalized diagnostics and treatment versatility in aiding the field of medicine, especially in seem further and further away. personalized diagnostics via CRISPR screening. However, when evaluating the future of CRISPR as Despite its vast potential, implementing CRISPR a whole, there is no doubt that it will ultimately make screen-informed gene therapy into clinical practice still groundbreaking changes to the state of modern medicine, faces diverse obstacles and limitations. Firstly, due to if not ubiquitously enter the clinical setting. From CRISPR unpredictable off-target effects, the efficacy of CRISPR screening to multiplex gene editing, CRISPR’s versatility, editing is far from clinical reliability.7 Even if we were precision, and efficacy is unparalleled. True, there are still to perfect CRISPR editing, screening cells also cannot countless obstacles in its trajectory, but CRISPR’s one-oftell the full story of diagnosing or predicting medical a-kind pros far outweigh the cons. Just like how there are conditions. Other factors, such as the environment or still “anti-vaxxers” despite effective vaccines, there will epigenetic regulation, could drastically give rise to new always be opponents to gene therapy despite substantial diseases.8 Similarly, analyzing gene expression on the CRISPR advancements. Nonetheless, government and cellular, or even tissue level can be at best marginally organization regulation is imperative moving forward. representative of overall organ function.9 Genetically The unmonitored recent Chinese CRISPR experiment evaluating all the genetic material contained in the body cannot be tolerated, and patents and intellectual property would be impossible; therefore, misrepresentative tissue will only become increasingly messy. As we continue samples could be sequenced, inadvertently avoiding appreciating the riches of serendipity and freedom, we need genetic defects elsewhere in the body. Moreover, in the to also remind ourselves that restructuring life’s building unlikely scenario that a viable CRISPR treatment is even blocks can just as easily manufacture a disaster as it can developed, there is no doubt that only the rich would be construct a success. Therefore, the FDA and regulatory able to afford it, leaving genetic diseases rampant among organizations worldwide need to keep a close watch on all the lower and middle class. Other social issues involve CRISPR advancements, ensuring that we are diagnosing backlash regarding ethics, religion, and philosophy; from and treating diseases that have plagued humanity for so “playing God” to creating “designer babies,” many fear the long rather than throwing humanity into disarray. potentially chaotic future of genetic Title and infographic designed by Farhaanah Mohideen | PHR Design Team

PENN HEALTHCARE REVIEW

A Trifecta of Culpability: Factors Contributing to the Obesity Crisis & Possible Future Solutions

Title designed by Judy Choi | PHR Design Team

By Sakshi Sehgal

ffecting nearly 40% of adults in America, obesity remains highly prevalent.1 A key concern is that this prevalence is only expected to increase, with statistics showing soaring obesity rates in the next decade.2 Specifically, extrapolated research indicates the potential that 50% of the population may be obese within 10 years.3 However, the condition of obesity is perhaps not as concerning as the severity of the high-risk conditions that may often result. Namely, individuals with obesity are significantly more predisposed to high-risk conditions, such as cardiovascular diseases, hypertension, and diabetes.4 Obesity affects all elements of our society; integrated in our daily lives—from our food choices to physical activity, the obesogenic environment infiltrates our sheer existence and will likely continue to do so in an incredibly pervasive manner in upcoming decades. 24

Title designed by Judy Choi | PHR Design Team

Thus, a question of culpability must be raised: which parties may be causally responsible for the current trends, and who or what institution ought to be tasked with addressing and working to rectify the issue as soon as possible. An evidence-based approach will be used to demonstrate the culpability of a multitude of factors—from lacking government regulation to individual choices, but also to identify a promising framework for a long-term solution: one that doesn’t merely offer an ambiguous public health model, but rather an approach combining explicit government intervention, radical cultural/ideological shifts, and specific grassroots efforts beginning during childhood. Firstly, there must be an initial consideration about the source of obesity. However, the literature does not appear to agree upon one but rather a combination of

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different influencing factors contributing to the state of the current obesogenic environment—basically, one “contribut[ing] to obesity.”5 Lang and Rayner highlight a trifecta of contributing factors: markets, governments, and consumers.6 Though other literature directs attention towards one or two of these factors as the more culpable ones, the combination of these three is, arguably the most powerful approach when addressing obesity. This is primarily because of the relatively equal considerations of the causal responsibility of each of the factors, which may prove useful when working towards specific/directed efforts for a solution. Firstly, markets fail because of their deliberate advertising and successful provision of knowingly unhealthy foods.7 Market failure in this sense refers to a responsibility of these key settings of consumption towards the health of the consumers; the failure derives from a lack of fulfillment of this role towards purchasing individuals. Namely, in order to “build brand value” and effectively exploit the psyche of consumers, high-calorie, low-nutrition foods are often strategically advertised-- for instance, when walking down a grocery store aisle, it is often the case that the flashiest, most attractive snacks at the beginning of an aisle are also often the unhealthiest.8 Corporations also fail in a similar vein—benefiting off of the profits of unknowing consumers.9 Because many products fail to adequately display nutritional facts (in an easily visible and accessible fashion), as well as potential long-term harms with overconsumption, the average consumer is ultimately unknowing of the potential harms of many unhealthy products. Secondly, consumers hold some responsibility because they follow such attractive advertisements and fall prey to a “price-led,” instead of “nutrition-led” diet, and they engage in sedentary behaviors that further limit a healthy lifestyle.10 Lastly, governments form the third portion of this dangerously culpable trifecta. The lack of government regulation, visible both, for instance, in no monitoring of corporate advertising or mandating of physical activity, actively contributes to the obesogenic environment.11 Furthermore, the subsidization of overproduction of fatty and sugary foods as opposed to those that are “micronutrientrich” and permitting inadequate education on the benefits of healthy eating and physical activity all constitute realms in which the government has failed to fulfill its duty.12 So, if we can recognize the main factors that contribute to the current state of

the obesogenic environment, what is the best longterm method to help address obesity? Once again—a combination of efforts is needed. Though some literature advocates for a vague renewed public health model, or one with ambiguous measures directed towards health advice, education in schools, etc., this ultimately remains ineffective because a much more directed, specific effort is necessary. Indeed, the most effective approaches in the past have been more targeted, concerted efforts on a grassroots scale, such as those that generate coalitions of individuals committed to healthy eating, for instance.13 Catering this approach towards the specific kinds of failures discussed in the previous paragraph is our best hope for rectifying the complex problem of obesity in the long run. With respect to lacking government regulation, for instance, a smallscale approach must be taken that addresses one aspect at first, say, corporate advertising. When discussing changing public health policy, such a small-scale approach might begin with a local community and certain key retailers of commonly-consumed products and then slowly expanded to a larger scale. By forcing companies to explicitly discuss potential long-term harmful health effects—such as what pharmaceutical companies are required to do—the government will fulfill its core role of proactively caring for its citizens’ well-being. An additional specific grassroots effort would be to mandate a certain amount of physical activity in schools and to require detailed, consistent education on the importance of healthy eating and exercise.14 By requiring such a program, instead of merely having half-hearted, sporadic efforts across the country, tangible and meaningful steps can be made in a direction of sustaining this knowledge into adulthood and promoting more healthful consumption. However, these efforts cannot be truly successful unless they are coupled with a somewhat radical ideological shift that prioritizes health. This could potentially look like an invigorated focus on healthy eating, more physical activity, etc. The combination of these efforts will hopefully simultaneously address the diverse contributors to the obesogenic environment. Unless a great segment of the population works to address a dangerous, weight gain-influencing environment, obesity will remain an undeniably pervasive and increasingly harmful threat to society. 25

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An Ethnographic Perspective on the Social Life of Maternal Mental Health in South Asia By Neelu Paleti

health condition. This will ultimately illustrate how the intertwined nature of these social complexities render treatment and guidance exceedingly difficult for women in South Asia and beyond.

A Historical Background of Mental Health in South Asia From a medical standpoint, PPD is known as the emotional distress that women may endure following the birth of a child. With dominating feelings of helplessness, guilt, and despair, mothers often lack a strong connection to their newborns in the early weeks of motherhood.1 PPD is one of many conditions that can negatively affect maternal mental health, and the focus is only now shifting to recognize these feelings as a medical experience by society. What separates each of these experiences are the varying triggers and manifestations of PPD symptoms. In the western world of medicine, this condition is primarily described as an imbalance of hormones or biological factors. Meanwhile, the same condition in South Asia could be the result of anything from the quality of relations with in-laws to the cultural stigma surrounding pregnancy. The maternal mental health of women in South Asia depends on a host of social, historical, and moral values that determines diagnosis and treatment patterns. This paper will explore the moral economy of womanhood and the larger social life of PPD as a

Local Biologies and Social Dynamics Populations of mothers from around the world each experience mental health complications in different ways. As explained by Lock and Kaufert through their comparative study on menopausal experiences of women Japan, Canada, and the U.S., a health condition cannot be conceptualized as a rigid set of biological symptoms but rather should be explained as the result of “local biologies” that determine the prognosis through a continuous interaction between biology and culture.2 When comparing the populations of mothers with PPD or other mental health conditions, local biologies, including religion, culture, socioeconomic status, family type, marriage stability, and more can all transform the experience and perception of the condition for each woman. The impact of these local biologies can be visualized and understood through the stark differences in experiences of women with PPD in the U.S. and South Asia. For example, a preliminary Internet search about PPD symptoms and risk factors in the U.S. reveals a highly clinical tone with an emphasis on hormonal imbalances and previous depressive episodes to be markers for the condition’s resulting mood swings.3 A longer list of risk factors includes a family history of depression, traumatic life event during pregnancy, alcohol or drug abuse, and financial stress.4 While there might be some overlap, the majority of these factors would

ew mothers across South Asia face a common yet unvoiced feeling. A feeling that is brushed aside by the sociocultural environment in which they live. This is not the same feeling of eager anxiety that they had after learning of their pregnancy. This is a feeling of being lost and unpassionate. The subtlety of this feeling is what makes it so hard to distinguish and diagnose. This is a feeling of postpartum depression (PPD).

FALL 2019

not apply to a large sector of the female population in South Asia. Family histories of depression can rarely be traced if the region never prioritized mental health care or diagnosis until recent years. Likewise, if only 5% of the female population engages in regular alcohol consumption in South Asia, alcohol and drug abuse rarely apply as a risk factor in this region.5 Even the medicalization of this type of postpartum depression may be a unique aspect of western medicine that is not highly known by medical providers or patients within South Asia. Many women are unaware that the stressful episodes they encounter following delivery have a defined name and medical condition attached.6 In this case, seeking care is not even considered, since the availability of treatment for such symptoms is rarely communicated to new mothers. Such circumstances highlight the importance of these local biologies and the variable nature of health conditions across different populations. The Moral Economy of Womanhood in South

of paternity leave.7 A simple policy such as this can shape and propagate the societal perspectives on a womanâ&#x20AC;&#x2122;s role in society. Furthermore, these social perceptions of womanhood raise controversies around contraception. The body of a woman is seen as the source of new life and limiting this source with the use of birth control options is widely discouraged or rarely used on a historical basis.8 This can also shape breastfeeding abilities of new mothers, as well. One of the most commonly cited points of distress amongst new mothers with PPD is the ability to breastfeed their newborn children.9 In the United Statesm baby formula and other substitutes are also widely used and socially accepted, unlike South Asia. Failing to breastfeed is seen as a form of weakness and failure in one of the earliest ways of supporting a newborn child in South Asia. Any mothers that cannot meet such societal demands are subject to criticism, both direct and indirect, from their communities.10

Concluding Thoughts While PPD itself may not be able to be completely solved through the introduction of these interventions, a working knowledge of the social determinants of maternal mental health can propel future interventions. Maternal mental health conditions are shown to be the worst in low-income countries, especially South Asia. The complicated nature of this problem prohibits the medical community from finding a onesize-fits-all solution that can mask the multifold origins of this issue. This health problem is more than just an issue of access to health, it is Title and pull quote designed by Lachlan Cormie | PHR Design Team a condition entangled in the social Asia life of mental health and the resulting norms and Nevertheless, the roots of maternal mental moral values. The definition and recognition of these health issues in South Asia can reach deeper to problems and the moral script found within each question the moral economy of womanhood. The population dictate how the women suffering from moral economy of womanhood is represented by these conditions are socially viewed. The first step in each regionâ&#x20AC;&#x2122;s paternity leave policy. Paternity leave is reducing such inequalities and bringing this distress legally mandated to be at least one or two weeks in to light is analyzing these social circumstances. This the United States and even longer in other western then paves the way for new solutions to navigate nations across Europe. However, India does not these complexities and achieve better mental health even enforce a minimum legally mandated period outcomes across South Asia and beyond.

"Many women are unaware that the stressful episodes they encounter following delivery have a defined name and medical condition attached."

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